Friday, June 25, 2010

The annual Commonwealth Fund study has found once again that the U.S. stacks up last in five measures of healthcare -- quality, efficiency, access to care, equity and healthy lives, compared with Britain, Canada, Germany, Netherlands, Australia and New Zealand. All these countries spend a fraction on health care compared with the U.S.

The new health reform law could address some of these deficiencies. But the findings are under attack from defenders of the status quo who claim in part that the problem is not in our health care system, but in our poverty rate.

Countries do have to do a number of things right to actually improve health:
1. Cover everyone for ready access to health care, to nip problems before they escalate, and to control chronic conditions with medicines or lifestyle changes.
2. Treat acute cases by well trained teams that have access to information about how to diagnose and treat hospitalized patients safely, and have the financial and organizational incentives to do so.
3. Reduce inequities that aggravate poor health, particularly economic differences between rich and poor, and social discrimination based on race, gender, sexuality, disability, etc. The stress of relative powerlessness takes a physical toll and compounds the lack of resources that can buy healthy circumstances: Violence-free neighborhoods where outdoor exercise is safe, healthy food and time to prepare it, spending on social programs like education and income support, information about sexual and physical health, as well as good health care.
4. Finally, it should be affordable so that everyone can use it, including those who need it most. This usually means authorizing the government to play a major role in negotiating prices with the health care industry.

U.S. is deplorably deficient in these areas of performance. And it doesn't all happen in lower-income states like Mississippi. Access is unquestionably a function in part of coverage and is equally wretched in California (where policy has been held hostage for decades to arcane but effective rules against social spending) as in the south. Preventable hospitalizations for chronic conditions vary by county as well as state and reflect poor access to primary care as well as demographic variables. Patient safety is a function of systems, and adequate staffing. Outside of the VA system, our acute care hospitals have insufficient standards for safe and efficient performance, which compromises patient safety and outcomes. In addition, uncontrolled high prices for overuse of medical technology drives the costs of care in the U.S.

Does all this, or even the promise that it will improve as reforms are implemented, justify cutting payments to disproportionate share (DSH) hospitals, as the new law proposes? Very debatable.

However. Let's grant that the U.S. has a higher percent of poor people than other countries, that people of color are disproportionately poor, and that poorer people in the U.S. tend to be in worse health. Dr. Richard Cooper, for one, suggests that the main reason we are outspending the world on health care is that we are spending more money taking care of our poor who are sick.

To the extent that this is true, it is only possibly the case because we take care of poor people in the worst possible way - not through universal access to timely primary care, but through crisis medicine when even U.S. standards generally would not tolerate outright denials of care.

We should have fewer poor people. Race should no longer be associated with poverty. Relatively lower income should no longer determine the degree of power and control over life circumstances that are in turn associated with longevity and good health (nor for that matter should gender, sexuality, religion, or most demographic factors and lifestyle choices; age of course is the exception.). We should not only continue to document these pernicious trends, we should turn our scholarship and advocacy to redressing them. Furthermore, our health care system can contribute to social equity, and presently does poorly.

An unspoken argument is that poverty and race account not only for our higher health care spending butt also for our worse health outcomes, so it will not help to look to reforms of the health care delivery system for solutions. I don't know whether rates of medical errors or C-sections (or misuse of neonatal intensive care units) are higher in the U.S. than in, say, Finland. I know that they are higher than they should be, that they are not disproportionately prevalent in "poverty ghettos," and that they contribute to unjustifiable costs and poor outcomes. Reforming the health care delivery system should not be an excuse for failing to remedy social inequalities. Pointing to inequalities cannot divert attention from the inefficiencies and remediable deficiencies in our delivery system.

The new health reform law and ongoing HHS initiatives make reasonable efforts to acknowledge and address access, inequalities, and delivery system reforms. They won't be as successful as they could be in a single payer system like Medicare and the VA, but even a single payer system in the U.S. would have to implement the kind of delivery and organizational reforms that are now before us.

It's 2005. Three southern Pacific countries including oil-rich Bunei get together with Chile and craft a trade agreement (on the edge of your seat yet?). The "P4"do not include standard U.S. trade rules that escalate drug prices and promote smoking. They do include some weak provisions on labor and the environment.

Fast forward to June 2010. No politician in the U.S. wants to run for reelection during a job-busting depression pushing for another free trade agreement. But tobacco giant Philip Morris, U.S.-based drug companies and other corporate interests think it would be just the thing.

So the U.S. invites the "P4"- Brunei Darussalam, Chile, New Zealand and Singapore - to join up in a Trans Pacific Partnership (TPP) with the United States, Australia, Peru and Viet Nam. The second round of talks descends on San Francisco from June 14-18, aiming for a "high-quality, 21st century agreement that builds on the standards of P4, setting it up as a platform for a regional trade agreement." (The first round was in Melbourne in March; next meeting set for Brunei in October.)

With a trade agenda in flux and facing demands for a voice in trade policy from public health, labor, environmentalists and consumers, the U.S. Trade Representative invited the Center for Policy Analysis on Trade and Health (CPATH) and colleague "stakeholders" to come inside. Sort of. Here's what we found.

The week's activities raised questions about whether there may be new opportunities in this Administration for shifts in trade policy, on public health, labor, development and the environment. US staff were consistently available and insisting that the Administration wanted a new era of transparency and consultation. Further they signaled that they wanted better labor standards; they were open to concerns about tobacco control, though they also said that some members of Congress would be ready to put the brakes on.

CPATH organized a press conference on opening day, where SF Supervisor Eric Mar and public health advocates called for removing tobacco from the negotiating table. We got good coverage, as did events organized by labor and environmental groups, and PETA. (The SF Board of Supervisors passed Supv. Mar's related resolution on June 22.)

While stakeholder groups have convened at the site of trade negotiations in the past, this time we were afforded the use of facilities inside the meeting area, and the opportunity to make presentations. Highlights of the week included well-attended presentations to the delegates by CPATH, the AFL-CIO, Public Citizen, IFG and others.

CPATH's presentation to trade delegates took place on the evening before the final day of negotiations. We identified the threats to health and health care posed by uneven and unsustainable development; investor-state rules that empower corporations to bring trade charges against governments; and rules that undermine tobacco controls, access to affordable medicines, and commitments on health care and health-related services. Every delegation attended except for Vietnam. The response was overwhelmingly positive.

At the same time, the usual shroud of secrecy surrounded the details of the talks. Morning stakeholder "briefings" were held by the U.S. chief negotiator Barbara Weisel, which focused broadly on what topics were being discussed, without any information on the content. The delegates were using "bracketed text" as the basis for some of their deliberations, but the U.S. would not make this text available for us to see.

This points to a key difference in access and participation between "stakeholders" and official trade advisers; stakeholders may participate in broad discussions about topics under consideration, whereas official U.S. trade advisers review and comment on U.S. negotiating positions and actual text to be negotiated. CPATH's national Campaign for Public Health Representation has focused on bringing public health advisers onto U.S. trade advisory committees, to balance the overwhelming representation by corporate interests. HR 2293/S 1644 seek to change this imbalance legislatively.

This is the perfect time for a campaign to add Congressional co-sponsors to HR 2293/S 1644, which will in turn add public health and consumers to trade advisory committees.